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1458 C/EBP Family Member Gene Fusions and Cooperating Genomic Events Define Two Distinct Molecular Sub-Groups in Adult B Precursor ALL

Program: Oral and Poster Abstracts
Session: 614. Acute Lymphoblastic Leukemias: Biomarkers, Molecular Markers, and Minimal Residual Disease in Diagnosis and Prognosis: Poster I
Hematology Disease Topics & Pathways:
ALL, Lymphoid Leukemias, Genomics, Diseases, Lymphoid Malignancies, Biological Processes, Molecular biology
Saturday, December 7, 2024, 5:30 PM-7:30 PM

Björn-Thore Hansen1,2,3*, Thomas Beder2,3,4*, Sören Döhle2*, Wencke Walter, PhD5, Malwine J Barz, PhD2,3,4*, Cecilia Bozzetti, MD2*, Johanna Horns2,3*, Axel Künstner6,7*, Alina M. Hartmann3,4,8*, Sören Franzenburg9*, Michael Wittig10*, Barbara Ritter11*, Stefan Schwartz, MD12*, Hauke Busch, PhD6,13*, Nikos Darzentas, PhD3,14*, Claudia Haferlach, MD15, Nicola Goekbuget, MD16, Monika Brüggemann, MD3,4,14*, Claudia D Baldus, MD3,4,14* and Lorenz Bastian2,3,4*

1(DFG, German Research Foundation): 413490537, Clinician Scientist Program in Evolutionary Medicine funded by the Deutsche Forschungsgemeinschaft, Kiel, Germany
2Department of Internal Medicine II (Hematology/Oncology), University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
3University Medical Center Schleswig-Holstein, University Cancer Center Schleswig-Holstein, Kiel, Germany
4Clinical Research Unit CATCH ALL (KFO 5010/1) funded by the Deutsche Forschungsgemeinschaft, Kiel, Germany
5Munich Leukemia Laboratory, Munich, Germany
6Medical Systems Biology Group, University of Lübeck, Lübeck, Germany
7University Medical Center Schleswig-Holstein, University Cancer Center Schleswig-Holstein, Lübeck, Germany
8Department of Internal Medicine II (Hematology/Oncology), University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
9Institute for Clinical Molecular Biology, Kiel University, Kiel, DEU
10Institute for Clinical Molecular Biology, Kiel University, Kiel, Germany
11Department of Hematology, Oncology and Immunology, Klinikum Kassel, Kassel, Germany
12Department of Hematology, Oncology and Cancer Immunology (Campus Benjamin Franklin), Charité – Universitätsmedizin Berlin, corporate member of Freie Universität and Humboldt-Universität zu Berlin, Berlin, Germany
13University Cancer Center Schleswig-Holstein, Lübeck, Germany
14Department of Internal Medicine II (Hematology/Oncology), University Hospital Schleswig-Holstein, Kiel, Germany
15MLL Munich Leukemia Laboratory, Munich, Germany
16Department of Medicine, Hematology/Oncology, Goethe University Frankfurt, University Hospital, Frankfurt, Germany

CCAAT-enhancer-binding proteins (C/EBP) are important regulators of myeloid differentiation and cell cycle control. The C/EBP family member CEBPE has been implicated in B precursor acute lymphoblastic leukemia (BCP-ALL) through IGH locus gene fusions and rare germline single nucleotide variants. ‘ZEB2 (p.H1038R)/IGH::CEBPE’ BCP-ALL is a provisional diagnostic entity in the current ICC classification. However, precise diagnostic definitions for this subtype are lacking.

We analyzed n=2,845 BCP-ALL transcriptomic profiles of own (GMALL: n=571; MLL: n=286) and published cohorts (St Jude: n=1,988), including pediatric (n=1,285) and adult cases (n=1,560). Of these, we identified n=43 BCP-ALL patients with either C/EBP family member gene fusions or corresponding gene expression signatures and absence of established subtype definition. To define the molecular profile of C/EBP BCP-ALL, we performed transcriptomic (RNA-Seq, n=31) genomic (WGS / WES: n=16; DNA EuroClonality capture analysis: n=23; SNP arrays: n=18) and epigenomic (DNA methylation arrays: n=17) profiling.

Unsupervised data analysis of the largest sub-cohort (n=25; GMALL) identified two distinct gene expression clusters – C1 (n=13) and C2 (n=12) – which shared overlapping gene expression signatures, separating C/EBP candidates from remaining BCP-ALL subtypes and from each other (C1 vs. C2). Robustness of this cluster separation was confirmed on gene expression data of independent cohorts (MLL: n=8; St Jude: n=10) and by unsupervised DNA methylation analysis of GMALL data.

Gene fusions involving C/EBP family members were clearly enriched in the novel gene expression clusters (n=36/43 vs. n=3/2,813 in remaining BCP-ALL; p<0.001) with n=7 cases sharing the gene expression profile without a C/EBP driver fusion call. CEBPE fusions were specific for cluster C1 (C1: n=11/25 vs. C2: n=0/18, p<0.001), while IGH::CEBPA (C1: n=8/25 vs. C2: n=11/18; n.s.) and IGH::CEBPB (n=5) or IGH::CEBPD (n=1)fusions occurred in both clusters. IGH locus DNA capture analysis identified in n=6/25 GMALL cases C/EBP fusions which were missed by RNA-Seq. Genomic profiling revealed subtype-specific cooperating events. Cluster C1 was characterized by ZEB2 p.H1038R (84%), NRAS/KRAS activating (74%) single nucleotide variants and CDKN2A deletions (88%; p<0.01 for all comparisons to C2 and to remaining BCP-ALL). C2 showed a less distinctive profile with enrichment of FLT3 activating SNVs (28%; p=0.01 for comparison to remaining BCP-ALL) and a tendency for IKZF1 deletions (42%; n.s.). Notably, ZEB2 p.H1038R was also observed in n=2 C2 cluster cases and in n=10 C cluster cases not harboring a CEBPE gene fusion, indicating that our gene expression clusters extend beyond the suggested genomic definition of ZEB2 (p.H1038R)/IGH::CEBPE. Comparison to normal B lymphopoiesis showed highest proximity of cluster C2 to pre-B I cells whereas C1 was closest to pre-B II cells, suggesting different developmental trajectories of C/EBP ALL subtypes.

C/EBP ALL was mainly observed in adults (median age: 46 years, range 13-88 years). A total of n=22 outcome-evaluable C/EBP ALL patients (median age: 49 years, range 18-70 years) were treated on GMALL protocols. One patient died during induction therapy. Complete MRD negativity in n=16/19 (84%) patients with MRD measurement after 1st consolidation indicated an overall favorable therapy response of C/EBP ALL. However, only n=15/22 (68%) patients achieved long-term complete remissions, including cases with allogenic stem cell transplantation in 1st CR (n=2). In total, n=8/22 (36%) patients experienced mostly late relapses with only n=3 patients achieving a durable 2nd complete remission after salvage. Despite favorable initial treatment response, C/EBP ALL patients might harbor an increased risk of late relapse, possibly related to their overall advanced age. Both clusters, C1 and C2 shared this clinical phenotype despite their distinct molecular background.

To facilitate diagnostic identification of C/EBP clusters C1 and C2, we trained a machine learning classifier on the GMALL gene expression data set which separated these from remaining BCP-ALL with accuracies of 99.7% in training data and 99.0% (MLL) or 99.4% (St Jude) in independent hold-out cohorts.

Integration of genomic, epigenomic and transcriptomic data defined two molecular distinct adult BCP-ALL subtypes harboring C/EBP family gene fusions.

Disclosures: Schwartz: Akademie fuer Infektionsmedizin e.V., AMGEN, CSi Hamburg, Pfizer, SERB SAS: Consultancy, Honoraria, Other: Travel Grants, AdBoard Member. Haferlach: Abbvie: Consultancy, Honoraria. Goekbuget: Amgen, Clinigen, Incyte, Jazz Pharmaceuticals, Novartis, Pfizer, Servier: Research Funding; Amgen, Astra Zeneca, Autolus, Clinigen, Gilead, Incyte, Jazz Pharmaceuticals, Novartis, Pfizer, Sanofi, Servier: Consultancy, Honoraria, Other: Advisory board. Brüggemann: Amgen Becton Dickinson AstraZeneca Jazz,Pfizer: Consultancy, Honoraria, Research Funding, Speakers Bureau. Baldus: Janssen, Astellas, Pfizer, Astrazeneca, Servier, BMS: Consultancy, Honoraria.

*signifies non-member of ASH